The Role of the Orthopaedic Surgeon in the Identification and Management of Nonaccidental Trauma

Abstract

Nonaccidental trauma (NAT) has short- and long-term effects on the patient. The importance of identification and management of injuries related to NAT can be vital to the disruption of patterns of abuse and can ultimately save lives. The purpose of this review is to educate the orthopaedic surgeon as the frontline provider in the treatment of these patients. Understanding the risk factors for abuse, sentinel signs on clinical examination, and questionable fracture patterns related to NAT enables providers to better identify and address children at risk of abuse or neglect. Equally as important, understanding pathologic states that can mimic NAT allows the orthopaedic surgeon the tools necessary to address all patients with multiple and/or unexplained fractures. Understanding the legal expectations and protections for practicing orthopaedic surgeons as mandated reporters and the importance of a multidisciplinary approach to intervention in these settings will improve patient experiences and outcomes.

Historically, the identification and diagnosis of fractures in young infants and children has raised concern for abusive, inflicted injuries, referred to as nonaccidental trauma (NAT). In the 1940s, radiologist John Caffey documented a case series of 6 infants with multiple fractures in various stages of healing, including metaphyseal fragmentation, external cortical thickening, and subdural hemorrhage raising concern for NAT,¹ and in 1962, Kempe et al² coined the term battered child syndrome to define a condition in which young infants and children sustained serious physical injury from abuse by a caregiver.

Subsequently, The Child Abuse Prevention and Treatment Act (Public Law 93-247) was enacted in 1974 as key federal legislation addressing NAT, defined at a minimum as “any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation; or an act or failure to act, which presents an imminent risk of serious harm.” Each state sets standards and definitions of child abuse and neglect based on federal law, but all 50 states, the District of Columbia, and US territories have reporting laws that mandate certain professionals, including orthopaedic surgeons, refer suspected NAT to child welfare service.³

This continuing public health crisis resulted in 4.1 million referrals to child welfare agencies alleging maltreatment involving 7.5 million children in 2017 alone; 674,000 children were confirmed victims of abuse or neglect, including 1,720 fatalities.³ Infants younger than 1 year are at a highest risk of abuse, victimized at a rate of 25.3 per 1,000 children and accounting for most NAT-related fatalities.³ Most abuse perpetration involved biological parents, deflating commonly held notions about “stranger danger.”

Child abuse-related statistics are likely underreported; the true prevalence of NAT is likely markedly greater because of underdetection. Adverse effects of NAT have lifelong ramifications including poor long-term physical and mental health outcomes, permanent disability, and even earlier death,⁴ which in turn affects society⁵ through increased healthcare costs, lost wages, and reduced productivity both among victims in adulthood and their families.

The Role of the Orthopaedic Surgeon

Fractures are the second most common injury caused by NAT after bruises.⁶ Among infants and young children, 12% to 20% of fracture injuries are attributed to NAT.⁷ As such, orthopaedic surgeons are at the frontlines providing care for suspected victims of NAT. Although accidental trauma is more common than abuse, maintenance of a high index of suspicion is critical to ensure that fractures due to NAT do not evade detection. As many as 20% of fractures in children younger than 3 years due to NAT are misdiagnosed or attributed to other causes, including medical diseases or underlying conditions.⁸ This failure to correctly attribute fractures secondary to NAT may result in risk of ongoing, even fatal harm to a child.⁸

Patient age, mobility, and fracture type should inform suspicion for NAT. Among nonambulatory infants, or young children with limited mobility, rib fractures, midshaft humerus or femur fractures, multiple fractures, and unusual fractures (scapula, vertebrae, sternum, or classic metaphyseal lesions of the long bones) as well as fractures without clear or reasonable mechanism of injury, or known cause of bony fragility, should include NAT in the differential diagnosis.⁹ In one recent study, characteristics including age less than 1 year, identification of multiple fractures, corner fractures, transverse fractures, and having public insurance were all associated with increased reporting of injuries as NAT to child welfare¹⁰; disparities in reporting NAT to child welfare agencies based on minority race/ethnicity and socioeconomic status have also been described.¹¹ Risk factors related to NAT have been reported (Table 1); however, no fracture type or pattern is diagnostic of or pathognomonic for abuse and any fracture in any child of any age, race, or socioeconomic status may be due to NAT. NAT may also be misdiagnosed if caregivers provide inaccurate or false histories¹² or if radiologic studies are incorrectly interpreted.¹³

Table 1 - Risk Factors for Nonaccidental Trauma^9,20

Child-Related Risk Factors	Caregiver-Related Risk Factors	Environmental Risk Factors
Boys > girls Twins Prematurity Chronic illness Physical or developmental disabilities Unwanted child Unplanned pregnancy	Poor impulse control substance/alcohol abuse Depression or other mental illness Low self-esteem Unemployment Parent abused as a child Young maternal or paternal age Poor knowledge of child development or unrealistic expectations for the child Negative perception of normal child behavior	Poverty Living with an unrelated adult Social isolation Single parent Non–biologically related male living in home Intimate partner violence

As an evaluator of young infants and children with bony injury, the orthopaedic surgeon is critically positioned to detect abuse, and it is essential that the orthopaedic surgeon has sound, general knowledge about NAT. Both the American Academy of Pediatrics (AAP)^9,14 and orthopaedic literature provide several clinical references to guide the orthopaedic surgeon in evaluating presentations suspicious for NAT.^15–17 However, feeling comfortable diagnosing NAT may not be uniform. Tenenbaum et al¹⁸ found that although over 89% of orthopaedic surgeons surveyed felt that it was their responsibility to report fractures suspicious for NAT, orthopaedic surgeons generally could benefit from improved child physical abuse detection training.

The Orthopaedic Encounter

Orthopaedic surgeons evaluate injured young infants and children in a variety of care settings, from the outpatient office to the adult or pediatric emergency department (ED) with nonuniform clinical and multidisciplinary team (MDT) resource availability. Although detailed history gathering and physical examination (PE) performance should be the same across care settings, imaging, laboratory testing, reporting to child welfare, and discharge from care vary based on the age of the child and the care setting. Infants are at the highest risk of abuse and warrant the most extensive NAT evaluation for occult injury often necessitating transfer to an ED or hospital skilled in treatment of trauma victims. Infants and children with fractures undergoing evaluation for NAT may require hospital admission based on severity of injury or pending a safe discharge plan determined by child welfare. In some care settings, MDT resources such as a skilled social worker, forensic nurse examiner, or Child Abuse Pediatrician (CAP, a pediatrician with subspecialty training in abusive injuries, an American Board of Pediatrics board–certified subspecialty since 2009) may be available to assist with care of the NAT victim. The following suggested approach accounts for variation in presentation by age, care setting, and resource availability.

History

A thorough history should be gathered both from the caretaker and, if developmentally appropriate, from the child in isolation in a nonaccusatory, nonleading manner, allowing for detailed narrative responses without interruptions; asking clarifying questions can be helpful.⁹ The caregiver providing the history may or may not be the perpetrator of NAT. Table 2 delineates the key points to address in the history of present illness, medical history, and family history, including accurate medication use and any concerns for inherited bone fragility, connective tissue, or genetic disorders.

Table 2 - Pertinent Points for Historical Examination in Nonaccidental Trauma^9,19

History of Present Illness	Medical History	Family History	Developmental History—Best When Directly Observed
Mechanism of injury—if no history of trauma must document denial Witnesses to injury Where and when injury occurred What happened after injury When the child was noted to be injured/ill Onset of symptoms Events leading to seeking medical care	Pertinent birth history (ie, prematurity) Previous ED visits/hospitalizations Chronic medical conditions Previous injuries (ie, falls, fractures, burns, and bruises) Medications Review of systems	Maternal and paternal medical illnesses Maternal and paternal mental health conditions Concerns for bone fragility or inherited orthopaedic, connective tissue or genetic disorder	Gross motor milestones (ie, rolling, sitting, standing, walking, and climbing) Fine motor milestones (ie, passing objects from hand to hand, self-feeding, and holding a bottle) Social landmarks (ie, self-feeding and toilet training) Language skills (ie, words, clarity of speech, and imitation)

ED = emergency department

Mechanism of injury should be thoroughly documented; if no history of trauma is provided to account for the fracture, it is important to specifically ask whether trauma occurred and document denial of trauma.⁹ The caregiver should be asked about concerns for NAT causing or contributing to the child's injury. Historical indicators of NAT are listed in Table 3.

Table 3 - Historical Indicators of Abuse^9,14

Historical Indicators of Abuse
No/vague explanation for a significant injury
Denial of trauma in setting of significant bony injury
Mechanism of injury not consistent with fracture type, energy associated with fracture or severity of injury
Injury inconsistent with the child's physical and/or developmental capabilities
Inconsistent history across caregivers or changing histories provided by caregivers
Different witnesses with different explanations
Injuries resulting from a family/domestic violence incident
Previous history of inflicted trauma
Witnessed inappropriate behavior to a child placing them at risk of NAT
Delay in seeking care for injury

NAT = nonaccidental trauma

Documenting developmental history is critical,¹⁹ and when possible, developmental status should be assessed by direct observation.¹⁹ Bony injury due to NAT decreases markedly among ambulatory children with more sophisticated mobility.⁷ Therefore, diagnosis of a fracture in an infant or young child whose developmental status is incompatible with the identified injury suggests that NAT is the likely etiology.

Social history allows for assessment of psychosocial risk factors, as listed in Table 1, which may place an infant or child at a higher risk of NAT.^19,20 Although best assessed by a skilled social worker, when unavailable, the orthopaedic surgeon should at a minimum assess safety risks, such as intimate partner violence (which often co-occurs with child physical abuse²¹) or drug exposure (which often co-occurs with abuse and neglect). Considered risk factors for NAT, psychosocial factors are not strong determinants,²² and NAT detection necessitates avoidance of stereotyping.

Physical Examination

A focused PE may result in a missed NAT diagnosis; comprehensive examination is vital. PE should be performed with the infant/child undressed in a gown⁹ and before cast placement, examining for pain, altered mental status, cutaneous injury, other bony trauma, or occult head and abdominal injury. General inspection of the head, eyes, ears, nose, throat, skin, abdomen, and extremities is crucial for identification of NAT. Physical and behavioral signs of trauma are listed in Table 4.

Table 4 - Physical and Behavioral Signs of Abuse and Neglect^9,37

Physical Signs of Abuse	Physical Signs of Neglect	Behavioral Signs of Abuse or Neglect
In nonambulatory infant:  Bony injury  Intraoral injury (frena)  Bruises  Intracranial/intra-abdominal injury Scalp swelling Subconjunctival hemorrhage Patterned injury: loop, hand print Injuries in various stages of healing TEN-4:  Bruising in the Torso/Ears/Neck <4 years of age  Bruising present in ANY region <4 mo AND  No confirmed accident in public setting that accounts for bruising in TEN region or infant <4 mo Injuries to nonbony or unusual location:  Torso, buttocks  Ears (pinna)  Face  Neck  Upper arms Bite marks Burns  Well demarcated  Circumferential  Symmetric  Involve unusual locations  (ie, genitals or bilateral lower  extremities)	Signs of malnutrition:  Skin  Hair or nail changes  Alopecia  Temporal wasting  Lanugo Poor hygiene:  Matted hair  Skin  Body odor  Dirt under nails Unattended physical/medical issues (ie, dental caries)	Sudden changes:  Weight/appetite changes  Sleep changes  Changes in academic performance Possible behavior:  Encopresis  Enuresis  Learning problems  Difficulty concentrating  Hypervigilance  Desire to avoid home  Reluctance to be around  an abusive caregiver

Documentation of injuries with location, size, color, and shape of the injury is crucial⁹; photodocumentation of injuries should be strongly considered, either by the orthopaedic surgeon or by a skilled MDT member (forensic nurse or CAP). Skin injuries in unusual locations (such as the pinna [Figure 1], back of the ear, buttocks, and thighs) or with unusual patterns (such as stocking glove or the shape of an object [Figures 2 and 3]) should be noted. Skin injuries are the most common and readily visible injuries due to NAT but are missed as sentinel injuries in almost half of fatal and near-fatal injuries.²³ Tenderness to palpation of the chest/abdomen or abdominal distension should be noted, and careful palpation of the legs, arms, feet, hands, ribs, or head may reveal acute or healing fractures.⁹ Abnormalities involving other organ systems may be indicative of additional occult NAT, meriting further evaluation including head or abdominal imaging and serum laboratory studies.

Figure 1: Photograph showing pinna ecchymosis.

Figure 2: Photograph showing patterned iron burn on the thigh.

Figure 3: Photograph showing loop imprint on the thigh.

Diagnostic Imaging and Laboratory Studies

Imaging studies aid in the diagnosis of NAT. Fracture patterns with high specificity for NAT are sustained by mechanisms associated with NAT including high-energy scapula, spinous process, sternal, metaphyseal corner, and rib fractures, especially posteromedial and lateral rib fractures.²⁴ Anteroposterior compression of the chest levers the posterior ribs over the fulcrum of the transverse process causing posteromedial and lateral rib fractures²⁵ (Figure 4). Metaphyseal corner fractures (Figure 5) are Salter-Harris II fractures where the “Thurston-Holland” fragment can, depending on the angle of the radiograph, appear like a “corner” or “avulsion” fracture; these fractures result from shearing mechanisms secondary to flailing of the extremity (such as during abusive shaking of the body), yanking, or using the extremity as a lever. Transphyseal distal humerus, vertebral body fractures, digital fractures, complex skull fractures (Figure 6), bilateral or multiple fractures, and fractures in different stages of healing are of moderate specificity for NAT.²⁴ Although common, current AAOS guidelines support consideration of NAT when femoral shaft fractures are detected in children younger than 3 years.²⁶ Detection of injuries without known mechanisms, or histories inconsistent with healing characteristics visible on imaging, also supports concerns for NAT.

Figure 4: Radiograph showing posteromedial rib fractures.

Figure 5: Radiographs showing classic metaphyseal lesion: AP and lateral views of the right distal femur.

Figure 6: Cranial fracture: cross-table radiograph and 3D reconstruction.

Skeletal survey (SS) (Table 5) is a powerful adjunct to the diagnosis of occult injury in a young or noncommunicative child by demonstrating occult fractures and their stages of healing (Table 6). The AAP considers SS a mandatory component of the evaluation of a suspicious injury in any child younger than 2 years⁹ and recommends this study be repeated in 2 to 3 weeks to assess for healing of non- or minimally displaced injuries (such as rib fractures) or better distinguish normal variants from healing injuries.²⁷ Yield of SS decreases as children become more independently mobile; therefore, performance in children older than 2 years is based on clinical discretion⁹ but could be considered in cases in which a child is nonambulatory, neurologically devastated, medically complex, or afflicted with an underlying bone fragility disorder. Repeat imaging with nuclear bone scan can identify new findings in more than 10% of cases; however, it is waning in use and is not recommended as a substitute for the initial SS.²⁸ Newer modalities including low-dose CT chest imaging can increase the diagnostic sensitivity for rib fractures better than repeated SS.²⁹

Table 5 - Complete Skeletal Survey Table²⁸

Appendicular Skeleton	Axial Skeleton
Arms (anterior-posterior [AP]) Forearms (AP) Hands (posterior-anterior [PA]) Thighs (AP) Legs (AP) Feet (AP or PA)	Thorax (AP and lateral), to include thoracic spine/ribs Abdomen (AP) Lumbosacral spine (AP and lateral) Bony pelvis (AP) Cervical spine (AP and lateral) Skull (frontal and lateral) (If head injury: 4 view right and left lateral, townes and AP)

Current AAP guidelines⁹ recommend concurrent use of SS with advanced imaging and clinical examination to evaluate for occult injury in the head and abdomen and other forms of abuse (ie, sexual abuse and neglect). Head injury is the leading cause of death from NAT in children younger than 2 years,³⁰ and abdominal trauma is the second. Although abdominal trauma related to NAT is seen in all age groups, the peak incidence of severe and fatal NAT abdominal injuries is in toddlers.³¹

Both CT and MRI are acceptable diagnostic imaging modalities to assess NAT victims with possible associated head injury.³⁰ Emergent evaluation of head trauma in symptomatic infants or children should include noncontrast CT of the head with 3D reformatted images of the calvarium for evaluation of intracranial bleeding and skull fracture³² and the benchmark full-sequence MRI of the brain and cervical, thoracic, and lumbar spine as soon as possible.³² MRI better demonstrates anatomic detail, cortical contusions, parenchymal lesions, shear injuries, and hypoxic ischemic insults, permits aging/dating of head injury, and may predict neurologic recovery or developmental delay/deficits. Bony spinal injuries are rare; however, MRI demonstrates ligamentous injuries in almost 80% of patients with known NAT-related head trauma in stark contrast to accidental head-injured patients.³³

Universal screening is recommended for occult head injury in neurologically asymptomatic infants younger than 1 year with any high-risk criteria (ie, rib fractures, multiple fractures, facial injury, and age less than 6 months²⁷), and clinicians should have a low threshold for neuroimaging when NAT is suspected in a young child.³⁰ Children younger than 2 years are considered at a highest risk of head trauma.³⁰ Additional studies are required to guide age-appropriate use of neuroimaging tests; liberal screening is recommended.

Liver and pancreatic enzyme tests (ie, aspartate aminotransferase, alanine aminotransferase, amylase, and lipase) and urinalysis are helpful in diagnosing occult abdominal trauma in suspected NAT victims; if abnormal, CT of the abdomen/pelvis with IV contrast should be considered.⁹ Tests for hematologic disorders should be considered in the setting of bruising.⁹

Bone health laboratory testing should be considered when fractures are identified; minimum recommended labs include calcium, phosphorus, alkaline phosphatase, vitamin D, and parathyroid hormone levels.⁹ In special circumstances when concern for scurvy, copper deficiency, or osteogenesis imperfecta exists, serum copper, vitamin C, ceruloplasmin, or venous blood for DNA analysis (or skin biopsy for fibroblasts) can be considered.⁹ Laboratory testing guidelines relate to injuries identified and differential diagnosis (Tables 7 and 8).

Current guidelines from the AAP⁹ lack age cutoffs for the use of imaging or laboratory testing in NAT screening; however, in general, the youngest infants (at the highest risk of abuse) should have the most comprehensive evaluations. Recommended utilization of studies is discussed in Table 9. Because additional diagnostic imaging and laboratory studies are routinely recommended for many suspected NAT victims, referral to the nearest ED may be appropriate, especially in circumstances in which an infant or child has additional injury detected or requires admission for treatment and/or safety planning (Table 6).

Table 6 - Guidelines for Skeletal Survey

Age-Specific Guidelines	American Academy of Pediatrics38	American College of Radiology28	Institution Pathway Example39
0-23 months	History of: Confessed abuse Injury during domestic violence Effect from toy or another object Delay in seeking care >24 hr in the child with obvious signs of distress Additional unrelated injuries (ie, bruises, burns, and whip marks) No history of trauma Exception (>12 mo): distal radius/ulna buckle, spiral tibia/fibula fracture	Suspected child abuse without neurologic or visceral injuries clinically suspected Neurologic signs or symptoms Apnea Complex skull fracture Other fractures Injuries highly suspicious of child abuse Suspected child abuse with initially negative skeletal survey—recommend repeat at 2 wk	Irritable infants <6 mo without fever or other identifiable cause ALTE's Altered mental status Respiratory distress Unexplained vomiting Unexplained bruising
0-11 months	All fractures Exceptions:  In cruising child >9 mo with a history of a fall: distal radius/ulna buckle fracture or spiral fracture of the tibia/fibula  Linear, unilateral skull fracture in the child >6 mo with a history of significant fall Clavicle fracture likely attributed to birth (acute fracture in infant <22 days old or healing fracture in infant <30 d old)	No separate guidelines	Same as AAP guidelines
12-23 months	Rib fracture Classic metaphyseal lesion Complex or ping-pong skull fracture Humeral fracture with epiphyseal separation attributed to a short (<3 feet) fall Femur diaphyseal fracture attributed to a fall from any height	No separate guidelines	Same as AAP guidelines
Additional	—	Older child (>24 mo) Neurologic signs or symptoms Apnea Complex skull fracture Other fractures Injuries highly suspicious of child abuse Suspected thoracic or abdominopelvic injuries:  Abdominal bruising  Distension  Tenderness  Elevated liver/pancreatic enzymes	No SS without other clinical concerns for abuse in children 12-23 mo who are ambulatory with:  Distal spiral fractures of the tibia/fibula with a history of fall while walking/running  Distal radius/ulna buckle fracture with a history of a fall onto an outstretched hand

AAP = American Academy of Pediatrics, ALTE = apparent life-threatening event, ED = emergency department, SS = skeletal survey

Table 7 - Injury-Related Laboratory Workup⁹

Injury	Laboratory Testing
Abdominal injury	AST, ALT, amylase, lipase, and urinalysis
	If abnormal—CT of the abdomen/pelvis with IV contrast
Bruising	CBC with differential, prothrombin, partial thromboplastin time, and von Willebrand factor
Fracture	Calcium, phosphorus, alkaline phosphatase, vitamin D, and parathyroid hormone

ALT = alanine aminotransferase, AST = aspartate aminotransferase

Differential Diagnosis

Tables 7 and 8 define syndromes and nutritional deficiencies that should be considered in possible cases of NAT. Certain underlying conditions, such as bone fragility, can present similarly to NAT. While maintaining a strong suspicion for NAT, a broad differential diagnosis facilitates obtaining a correct and timely diagnosis of these conditions.

Table 8 - Differential Diagnosis^14,40

Syndromes
Syndrome	Mechanism	Inheritance	Radiologic Findings	Orthopaedic Management	Medical Management
Osteogenesis imperfecta	Abnormality in collagen I affecting COL1A1 and COL1A2 genes	AD—Type I, IV AR—Type II (perinatal demise), III	Type I/IV: thinning of bone cortices and trabeculae	Normal bone healing; prevent and/or correct deformity avoid stress risers, intramedullary fixation with expanding rods	Diphosphonate treatment
Menkes syndrome	Abnormality in copper regulation affecting the ATP7A gene	X-linked recessive (terminal by age 3)	Osteopenia, Wormian skulls (failure to thrive, hypotonia, seizures, developmental delay, and coarse hair)	Supportive	No known treatment/cure
Juvenile idiopathic osteoporosis	Unknown	No known genetic mode of transmission	Diffuse osteopenia, thoracic or thoracolumbar kyphosis with codfish appearance, and long bone fractures with osteopenic callus formation in various stages of healing	Bracing treatment for spinal fractures and long bone fractures—avoidance of long-term immobilization	Calcitonin, calcitriol, estrogen, and diphosphonates

Nutritional Deficiencies
Condition	Cohort Affected	Deficiency	Labs	Manifestation	Radiographic Findings	Treatment
Osteopenia of prematurity	Premature infants with very low birthweights (<1,500 g)	Low substrate availability of calcium and phosphorous and low bone mass at birth in premature infants with low birthweights	Normal serum calcium until late in disease Serum phosphate: <1 mmol/L Low inorganic phosphate: <1.8 mmol/L Elevated alkaline phosphatase: >900 IU/L	Low bone mass at birth Poor bone mineralization Fracture Decreased growth velocity/height at termination of growth	Osteopenia, fracture	Formula supplementation: Calcium 40-70 mg·kg−1·d−1 and phosphorus 25-45 mg·kg−1·d−1 vitamin D: 400 U.I./d
Scurvy	Disordered eating, ketogenic diet	Vitamin C deficiency Loss of collagen triple helix binding resulting in primitive collagen	Serum vitamin C: <0.3 mg/dL	Weakened bone integrity and predisposition to subperiosteal hemorrhage, bleeding gums, and pseudoparalysis—perineural bleeding within the nerve sheaths	Osteopenia and cortical thinning Wimberger ring: thickening of the zone of provisional calcification Frankel line: physeal thickening and sclerosis	Resolves quickly with administration of vitamin C. 100 mg PO 3-5 times a day until a total of 4 g is reached, followed by 100 mg PO daily
Copper deficiency	Preterm infants (copper accumulates in third trimester), children with severe nutritional disorders (ie, short gut syndrome)	Abnormal lysyl oxidase inhibits normal collagen fibril cross-linking causing bony fragility	Serum copper concentration <0.45 mg/L; ceruloplasmin concentration <20 mg/L	Neutropenia; anemia	Cupping/fraying of the metaphysis, metaphyseal sickle-shaped spurs, osteopenia, and subperiosteal bone formation	Copper supplementation: 0.1 mg/kg of cupric sulfate per day. Adequate intake: Infants: 0-6 mo, 200 mcg (30 mcg·kg−1·d−1) 7-12 mo, 220 mcg (24 mcg·kg−1·d−1)
Vitamin D–deficient rickets	Chronically ill patients, dark-pigmented skin, poor nutrition, and exclusively breastfed infants	Poor mineralization of the cartilage and osteoid	Calcidiol (25-OH-D) concentrations <20 ng/mL	Poor mechanical properties of cortical bone, diminished longitudinal bone growth, and pathologic fracture	Widening of physis and metaphysis in a cup or flared shape, thinning of the cortices, bowing of the long bones, and deformities of the ribs, pelvis, and spine	Treatment for 2-3 mo: 1-12 mo: 1,000-5,000 IU/d >12 mo: 5,000 IU/d

Table 9 - Utilization of Imaging Modalities in Suspected NAT

Advanced Imaging Modality	ACR28	AAP9
Tc-99m whole-body bone scan	For use when skeletal survey (SS) is negative, but clinical concern is high. Not a substitute for SS	In setting of fracture can be used to complement SS. Not a substitute for SS.
Noncontrast head CT	Emergent in setting of head trauma, neurologic changes <24 mo: low threshold to image with negative skeletal survey	Emergent in setting of head trauma
Abdomen CT with contrast	Emergent in setting of abdominal trauma	Emergent in setting of abdominal trauma
Head MRI	Nonemergent cases for head imaging	Nonemergent cases for head imaging
C-Spine MRI	Nonemergent cases when imaging head	Nonemergent cases when imaging head to diagnose occult cervical injury
Skeletal survey	Initial imaging evaluation <24 mo Signs of intrathoracic or intra-abdominal visceral injury Child with neurologic signs/symptoms, complex skull fracture, apnea, multiple fractures, spine trauma, and facial injury Older children >5 yr: SS low yield; target imaging to suspected injury	Nonambulatory infants with bruises Infants and toddler with suspicious bruising Children <2 yr with abdominal trauma Children <3 yr with fracture concerning for NAT due to pattern, historical inconsistency Children with head trauma

AAP = American Academy of Pediatrics, NAT = nonaccidental trauma

Children with chronic illness or neuromuscular disorders may have accompanying sarcopenia, poor nutrition, and inadequate calcium and vitamin D intake.³⁴ The bone of children with chronic diseases suffers a multimodal affront secondary to proinflammatory cytokines in inflammatory conditions, direct metastasis in hematologic and malignant conditions, disuse from chronic hospitalization or lack of ambulatory ability, and vitamin D deficiency due to lack of sunlight exposure secondary to photosensitivity from antibiotics or immunosuppressant medications. In addition, glucocorticoid treatment decreases bone formation, increases bone resorption, and induces sarcopenia.³⁵ Studies have shown an inverse relationship between skeletal muscle fat content and bone strength.³⁴ As there are a multitude of etiologies for osteopenia in the setting of chronic disease and disuse, management is similarly complicated. To adequately address osteopenia in these patients, it is important to address extrinsic factors, such as vitamin D and calcium deficiencies, as well as lack of exercise, where remediable, while addressing imbalances in bone resorption and deposition.

Management After Diagnosis

Diagnosis of NAT may occur in any care setting; however, utilization of an MDT can optimize care. Skilled social workers, forensic nurses, and CAPS with additional training in the evaluation of NAT may provide ancillary opinions about fracture biomechanics and injury plausibility, recommendations for occult injury screening (including for at-risk contacts living in the child's home), and support consideration and testing for underlying bone fragility, genetic disease, or differential diagnoses. MDTs can facilitate reporting of NAT to child welfare and ongoing communication with investigators and provide needed testimony in medicolegal proceedings. If unavailable, the orthopaedic surgeon should consider consultation with a nearby children's hospital or larger medical facility with additional CAP-focused MDT resources either by telephone or through transfer.

Transferring care to another physician or medical facility does not negate the treating orthopaedic surgeon's mandated responsibility to report suspected NAT at the time concerns are recognized. The orthopaedic surgeon should still contact the appropriate authorities to report the suspected abuse. There is no requirement to determine the perpetrator or exact details of a traumatic event; however, reporting suspicion of NAT is considered compulsory to the diagnosis.⁹ Once reported to child welfare, the orthopaedic surgeon should inform the child's caregivers that a report has been made using upfront, clear, and nonaccusatory communication framed in child safety. Ultimate decisions about case disposition (including, potentially, discharge home to the caregivers) are made by child welfare investigators and not determined by the orthopaedic surgeon, and the orthopaedic surgeon should feel comfortable communicating this to caregivers when notifying them of the report. Ideally, social workers and specialized MDTs are available to assist; however, the orthopaedic surgeon should be prepared to recognize NAT, initiate laboratory/diagnostic testing for occult injuries, and report concerns to child welfare services independently.

Hesitance to report NAT to authorities may occur for multiple reasons. Fear of disrupting the collegial patient-physician relationship³⁶ and possible malpractice suits or other legal entanglement may result in failure to report; orthopaedic surgeons may also have concern around NAT likelihood or feel pressured to have certainty. Reporting may also cause psychological distress to the reporter, as violence directed toward children can cause varied responses including sadness, rage, or secondary traumatic stress among those who detect it. Child abuse mandated reporting laws require only that orthopaedic surgeons have reasonable suspicion for NAT to meet the threshold of mandated reporting; certainty that an injury is NAT is not required. Reports made to authorities in good faith are immune from legal liability, whereas failure to report risks legal, civil, financial, and other licensure penalties.¹⁵

Once suspected NAT has been reported, the orthopaedic surgeon may be asked to provide information regarding the history, PE, and diagnosis to an assigned investigative caseworker from child welfare and/or law enforcement. Investigators will gather history from the caregivers and/or child directly, may perform a scene investigation (such as doll re-enactment) and/or depending on the level and nature of safety risks identified, take temporary custody of the child while further information is gathered. During this time, the child may require admission to the hospital for safety planning, be discharged to kinship care (temporary placement with other family members), or have a safety plan created by investigators to ensure temporary supervision of caregivers with the child. The orthopaedic surgeon should not discharge a child from care until indicated by the investigators to ensure the child's ongoing safety after medical care is complete.

The orthopaedic surgeon may be required to testify in either family court or criminal proceedings; the burden of proof for abusive injury in family court is a preponderance of the evidence, whereas for criminal court, the standard is beyond a reasonable doubt. When asked to testify, the orthopaedic surgeon should be prepared to discuss the details of the history, PE, and diagnosed injury and may be called upon to render an opinion regarding the mechanism of injury and abuse likelihood if qualified as an expert witness.

Summary

Most children presenting to the orthopaedic surgeon with fracture will not be victims of NAT; however, fracture is the second most common presentation of NAT after bruising. It is vital for NAT to remain in the differential diagnosis for all orthopaedic patients. When possible, identification of sentinel lesions and notification of authorities as a mandated reporter may prevent ongoing abuse and even fatality. Mandatory reporting in good faith is without legal liability, and as such, the orthopaedic surgeon should use their understanding of historical risk factors coupled with clinical patterns of injury to make educated decisions on when to report without fear of repercussions. As a frontline health provider for children with skeletal issues, orthopaedic surgeons are in a particularly vital position to identify and protect these children.